Provider Demographics
NPI:1528559077
Name:GORDON, CRYSTAL CIARA
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:CIARA
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 LAS POSAS RD APT 101
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-5719
Mailing Address - Country:US
Mailing Address - Phone:619-643-0662
Mailing Address - Fax:
Practice Address - Street 1:13950 MILTON AVE STE 220B
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-2939
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X, 247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other